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Improving health equity through new models of primary care: PLOS Medicine 15th Anniversary

Academic Editor Margaret Kruk celebrates 15 years of PLOS Medicine by discussing an article that described reductions in mortality rates following the expansion of family health services in Brazil. 


Ever since Julian Tudor Hart pointed out that good quality health services tend to flow to the richest rather than the sickest, the world has been struggling to measure, and mitigate the inverse care law.  If the main task of high-quality health systems is to improve population health and if primary care is a (the?) key platform to achieve equitable coverage of health services, then we need to know how it is doing at keeping people alive.  Yet fifty years post the historic declaration of Alma Ata, strikingly few new models of primary care have been rigorously evaluated.  We urgently need new models of primary care.


My favorite PLOS paper from the last five years is “Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis” (2017) by Thomas Hone, Davide Rasella, Mauricio Barreto, Azeem Majeed, and Christopher Millett.  Hone and colleagues use data from Brazil’s health information system to examine how expanding a specific model of primary care, the Estrategia de Saude da Familia or family health strategy, is related to age-standardized mortality rates among whites compared to black and mixed-race people in the country.  Theirs is among the first studies to link primary care expansion to reduced adult mortality and to show that the effects of primary care are pro-poor.


Cesar Victora and colleagues, incidentally also from Brazil, have led the way in tracking equity of service access and of outcomes across the globe.  The Hone paper builds on this base to link health services to outcomes, thus injecting a measure of accountability into the system.  Health equity analyses are essential in all countries, including low- and middle-income countries, as the mean often obscures dramatic differences in health and health care.


Why does it stand out?  It combines salience with scale and rigor.  It tackles a hot topic—the health effects of primary care—for which the current debate has generated more heat than light.


It is a national study, which elevates its policy importance.  Policymakers have scarce time to parse scientific evidence and small, local studies have little chance of rising to their attention in the way that a large national study will.  Hone and colleagues use administrative data—indeed all data were in the public domain.  This is both efficient science (no need for additional surveys) and increases Brazil’s return on investment in measurement.  As the authors note, there is also a downside to using administrative data: inconsistent quality.  In this case, causes of death were poorly coded and some required reclassification.  While this is not ideal, the authors conduct a suite of sensitivity analyses to test robustness of their findings.  From a societal perspective, the use of data in research and beyond is key to improving it—bad data thrive in the shadows.


Finally, the analysis examines potential pathways for their positive results; this is still too uncommon in health systems research. An impact of the family health strategy on mortality is only plausible if it reduces deaths from conditions amenable to primary care and not others.  Hone and colleagues show that expansion of primary care was associated with reductions in mortality from cardiovascular disease, diabetes, and infectious diseases—the bread and butter of primary care—but not from motor vehicle accidents that are not amenable to primary care.


Over the past 15 years PLOS Medicine has created an open access platform for rigorous and important science.  This study sits squarely in PLOS Medicine’s sweet spot: relevant, timely, and technically sophisticated.




Dr. Margaret E. Kruk is Associate Professor of Global Health at the Harvard T.H. Chan School of Public Health.  Dr. Kruk’s research generates evidence on how health systems can improve health in low-income and middle-income countries.  She develops novel measures of health system quality and studies the links between quality and population demand for health care, health outcomes, and confidence in the system.  She uses novel implementation science methods to evaluate large-scale health system reforms.  She currently collaborates with colleagues in Ethiopia, Kenya, Nepal, and India.

Dr. Kruk recently chaired the Lancet Global Health Commission on High Quality Health Systems in the SDG Era (HQSS Commission), a global initiative to redefine and measure quality in the health systems of lower-income countries.  Previously, Dr. Kruk was Associate Professor of Health Policy and Management and Director of the Better Health Systems Initiative at Columbia University.  She has held posts at the United Nations Development Program and McKinsey and Company and practiced medicine in northern Ontario, Canada.  She holds an MD degree from McMaster University and an MPH from Harvard University.  She is also an Academic Editor for PLOS Medicine. Follow her on Twitter @mkruk



Image Credit: johnpotter, Pixabay (CC0)

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